Physiotherapy Management of Cancer-Related Lymphedema

Lymphedema is one of the complications that can arise from cancer or cancer-related treatments. Lymphedema can develop at any part of the body, depending on the site of the tumour and its treatment.

 

Upper limb lymphedema is most commonly found in breast cancer patients. About 8 to 56% of breast cancer patients develop lymphedema, two years post-surgery [1]. Lower limb lymphedema may arise from cancer of the cervical, uterine and prostate regions. Approximately 5 to 36% of patients with gynecological cancers were diagnosed with lower limb lymphedema [2].

Lymphedema may cause physical and psychological stress to patients. Therefore, it is important to identify and treat lymphedema as early as possible.

What is Lymphedema?

Lymphedema is an abnormal accumulation of protein-rich lymph fluids in the body tissue spaces, due to the disruption of the lymphatic system either from tumours, surgeries from cancer or radiotherapy. Lymphedema can be classified into either primary or secondary lymphedemas. Cancer-related lymphedema is classified as a secondary lymphedema.

Lymphatic System

The lymphatic system consists of lymphatic vessels and lymph nodes. The lymphatic system works closely with the blood vessel system. Its functions are to collect and transport fluid from body tissue spaces back to the vein in the blood system, to fight infections and to maintain fluid balance in the body.

 

Lymph Formation

Normally, water and nutrients carried in the blood vessels exit the vessels and enter the body tissue spaces to nourish the body cells. The lymphatic vessels will then pick up these water and nutrients, along with some waste products in the tissue spaces, forming lymph. Lymph is a clear, watery fluid consisting of water, fats, protein and white blood cells. Ultimately, the lymph will be returned to the blood system.

How does lymphedema occur?

The amount of lymph transported through the lymphatic vessels at any time is known as the lymph load. The lymph load can be variable. For example, when there Blood Vessel tissue space lymph lymphatic vessels Direction of Blood Flow Direction of Lymph Flow Formation of lymph is an infection or injury to the body, lymph load can increase.

A person’s transport capacity depends on the ability of the lymphatic vessels to hold and transport the lymph. Normally, we have a very high lymphatic transport capacity and as such, we are able to manage with any given amount of lymph load.

The transport capacity can be lowered, due to an obstruction in the lymphatic vessels. The obstruction can be caused by the tumour pressing on the lymphatic vessels or any surgery and/or radiotherapy involving the lymph nodes. Lymphedema will develop once the lymph load exceeds the lymphatic transport capacity.

Complications of Lymphedema

Lymphedema can be quite distressing and can affect one’s quality of life, if left untreated. There will be worsening of swelling, feeling of heaviness, aching, pain and discomfort of the affected limb. As a result, one may find difficulties in performing activities of daily living. Besides, it can cause psychological stress as patients may perceive disfigurement of the affected body part and hence withdraw from social events.

As the lymphedema develops, it will lead to tissue hardening (i.e. fibrosis) and may increase the risk of soft tissue infection (i.e. cellulitis). This may cause further progression of lymphedema and disability.

Therefore, early identification of this condition is important to prevent it from developing and early treatment can be started once it is diagnosed.

preventing lymphedema and the worsening of lymphedema

 

Treatment of lymphedema

 

Intensive

Most reduction is achieved in this phase, which lasts from two to five weeks. It should be done daily for 40 to 90 minutes for five times per week.

Maintenance

A phase of transition to self-care by patients.

The standard treatment for lymphedema is known as complete decongestive therapy (CDT). CDT is not a cure for lymphedema but it can help to control its symptoms.

Lymphedema must be treated by certified lymphedema therapists.

CDT consists of the following components:

  • Good Skin and Nail Care
    This is to maintain a good protective layer of skin to reduce the risk of infections.
  • Manual Lymph Drainage (MLD)
    This is a special form of massage to re-channel lymph fluid from affected areas to non-affected areas. For example, lymph fluid from the swollen left arm can be massaged or drained to the right armpit and neck, which possess many well-functioning lymph nodes. This massage is done in two phases: the intensive phase and maintenance phase.
  • Compression Therapy
    Elastic bandages or compression garments are used to control swelling. During the intensive phase, compression bandaging will stay on patients for the entire day except during showers. During the maintenance phase, a compression sleeve or stocking will replace the bandaging. These compression garments can be purchased ready-made or custom-made.

THERAPEUTIC EXERCISES

These exercises are done to facilitate general lymph flow.

Neck Exercise

  • Turn your neck from side to side gently.
  • Repeat 10 times, three sessions per day.
Shoulder Elevation Exercise

  • Lift the affected arm gently as high as possible, while taking a deep breath.
  • Lower the arm slowly and breathe out.
  • Repeat 10 times, across three sessions daily.
Elbow Exercise

  • Keep affected arm up, bend gently and straighten the elbow.
  • Repeat 10 times, across three sessions daily.
Hand Exercise

  • Keep the affected arm up, open and close palms.
  • Repeat 10 times, across three sessions daily.

 

  • [1] Paskett ED, Naughton MJ, McCoy TP, et al.: The epidemiology of arm and hand swelling in premenopausal breast cancer survivors. Cancer Epidemiol Biomarkers Prev 16 (4): 775-82, 2007. 
  • [2] Beesley, V., Janda, M., Eakin, E., Obermair, A. and Battistutta, D. (2007), Lymphedema after gynecological cancer treatment. Cancer, 109: 2607–2614. doi: 10.1002/cncr.22684.